Martin E. Franklin,
PhDAssistant professor of psychiatryCenter
for the Treatment and Study of AnxietyDepartment of
psychiatryUniversity of Pennsylvania School of
Medicine Philadelphia

Edna B. Foa,
PhDProfessor of psychiatryCenter for the
Treatment and Study of AnxietyDepartment of
psychiatryUniversity of Pennsylvania School of
Medicine Philadelphia

Adam, age 10, is
extremely distressed at school. Because of obsessional
contamination fears, he avoids contact with other
children and refuses to eat in the cafeteria. He washes
his hands 20 times per day and changes his clothes at
least three times daily.

His primary obsessions
involve contact with bodily fluids—such as saliva or
feces—and excessive concerns that this contamination
would cause him serious illness.

Adam’s parents
say their son’s worries about dirt and germs began when
he entered kindergarten. They sought treatment for him 2
years ago, and he has been receiving outpatient
psychotherapy since then. They have brought him to an
anxiety disorders specialty clinic for evaluation
because his obsessive-compulsive symptoms are
worsening.

When treating patients such as
Adam, our approach is to use cognitive-behavioral
therapy (CBT) and adjunctive drug therapies to relieve
their symptoms and help them reclaim their lives.
Diagnosis of pediatric OCD is often delayed, and few
children receive state-of-the-art treatment.1
The good news, however, is that skillful CBT combined,
as needed, with medication is highly
effective.

‘Contaminated’
mother.Adam becomes distressed when he comes
in contact with objects that have been touched by others
(such as doorknobs). He is especially anxious when these
items are associated with public bathrooms or sick
people.

Adam’s mother is a family physician who
has daily patient contact. In the last 6 months, Adam
has insisted that his mother change her work clothes
before she enters his room, touches him, prepares his
food, or handles his possessions.

As in Adam’s case, the family often gets caught up in
a child or adolescent’s obsessive rituals (Box
1).2 After a detailed discussion with
Adam and his parents and because his symptoms were
severe, we recommended combined treatment with
sertraline and CBT. Adam was willing to consider CBT and
medication because he recognized that he was having
increasing difficulty doing the things he wanted to do
in school and at home.

Snapshot of pediatric OCD
Approximately 1 in 200 children and
adolescents suffer from clinically significant
OCD.3 They experience intrusive thoughts,
urges, or images to which they respond with
dysphoria-reducing behaviors or rituals. Common
obsessions include:

fear of dirt or germs

fear of harm to oneself or someone else

or a persistent need to complete something “just
so.”

Corresponding compulsions include hand washing,
checking, and repeating or arranging.

OCD appears
more common in boys than in girls. Onset occurs in two
modes: first at age 9 for boys and age 12 for girls,
followed by a second mode in late adolescence or early
adulthood.

Two practice
guidelines address OCD in youth: an independent
expert consensus guideline4 and the American
Academy of Child and Adolescent Psychiatry’s practice
parameters for OCD.5

For
uncomplicated OCD, these guidelines recommend CBT as
first-line treatment. If symptoms do not respond after
six to eight sessions, a selective serotonin reuptake
inhibitor (SSRI) is added to CBT.

For
complicated OCD, medication is considered an
appropriate initial treatment. Complicated OCD includes
patients who:

or have comorbidity such as depression or panic
disorder that is likely to complicate treatment.

Keys to successful treatment
OCD is remarkably resistant to
insight-oriented psychotherapy and other nondirective
therapies. The benefits of CBT, however, are
well-established, with reported response rates of
>80% in pilot studies.6,7 Although
confirming studies have yet to be conducted, successful
CBT for pediatric OCD appears to include four elements
(Table
1).

Exposure and response
prevention (EX/RP) is central to psychosocial
treatment of OCD.7,8 In specialized centers,
exposure can be applied intensively (three to five times
per week for 3 to 4 weeks).9 In most
practices, however, exposure is more gradual (weekly for
12 to 20 weeks). With repeated exposure, the child’s
anxiety decreases until he or she no longer fears
contact with the targeted
stimuli.8,10

Not
‘misbehavior.’ Children—and less commonly
adolescents—with this disorder may not view their
obsessions as senseless or their compulsions as
excessive. Even when insight is clearly present, young
OCD patients often hide their symptoms because of
embarrassment or fear of being punished for their
behavior.

Response
predictors. A key to CBT in children or
adolescents is that they come to see obsessions and
compulsions as symptoms of an illness. The symptoms,
therefore, require a skillfully applied “antidote,” as
taught by the clinician and implemented by the child,
family, and others on the child’s behalf.

Besides overt rituals, three response predictors
include the patient’s:

desire to eliminate symptoms

ability to monitor and report symptoms

willingness to cooperate with treatment.

CBT may be difficult with patients younger than age 6
and will invariably involve training the parents to
serve as “coaches;” a CBT protocol for patients ages 4
to 6 is under investigation (H. Leonard, personal
communication). CBT also can be adapted for patients
with intellectual deficits.11

A ‘tool kit.’ Successful exposure
therapy for OCD relies on equipping children and
adolescents with the knowledge and skills to battle the
illness. They often have tried unsuccessfully to resist
OCD’s compulsions and must be convinced that EX/RP
techniques will work. Using a “tool kit” concept reminds
young patients that they have the implements they need
to combat OCD (Table
2).

A ‘germ ladder’ and ‘fear
thermometer.’Adam’s tools include a stimulus
hierarchy called a “germ ladder,” which the therapist
and Adam create collaboratively. It ranks stimuli from
low (his own doorknob) to very high (public toilets,
sinks, and door handles).

As part of his
treatment, Adam begins to touch objects in his room and
house while voluntarily refraining from ritualizing. He
uses another tool—a fear thermometer—to record his
distress level on a scale of 1 to 10 during and after
these exposures.

Adam discovers that when he
comes into contact with less-threatening items his fear
ratings typically return to baseline within 20 to 30
minutes. This insight helps him modify his assessment of
the risk they pose.

During office visits, he
confronts similar items around the clinic, with the
therapist providing encouragement and instruction for
additional exposure homework. Eventually Adam works on
the clinic’s public bathroom, which he perceived to be
relatively clean but less so than his own bathroom.
After fear in response to this bathroom is reduced, the
therapist and Adam graduate to more-public facilities,
such as the bathrooms at Adam’s pool and the local train
station.

Exposure
therapy. EX/RP is most successful when the
child—rather than the therapist—chooses exposure targets
from a hierarchy of fears,2 particularly when
the list includes behaviors the child is resisting. In a
collaborative spirit, the child takes the lead in
placing items on the hierarchy and deciding when to
confront them.

The therapist and child revise the
hierarchy periodically, which demonstrates progress and
allows them to add items as the child overcomes fears
that cause less distress.

Reducing need for
reassurance.Adam has a habit of repeatedly
asking his mother whether contact with particular
objects in public is risky. By the third treatment
session, he and the therapist agree that he will try to
refrain from asking such questions.

His mother,
in turn, is asked to reiterate the rationale for
response prevention whenever Adam slips. She will offer
encouragement and support without answering “OCD’s
questions.”

Adjunctive drug
therapyWhile Adam is working with the
behavioral therapist to reduce his anxieties and need
for reassurance, he is also receiving gradually
increasing dosages of sertraline. As discussed, he is
considered a candidate for CBT plus medication because
of his symptoms are severe. Drug treatment can benefit
most pediatric OCD patients.

SSRIs. Two SSRIs are approved for
pediatric OCD—fluvoxamine for ages 8 to 18 and
sertraline for ages 6 to 18. Most SSRIs are likely
effective for OCD in youth (Table
3),12-14 although reports have suggested
a link between paroxetine and suicidality in pediatric
patients. Other options may be more suitable choices
unless further evidence supports the use of paroxetine
as a first- or second-line agent for pediatric
OCD.

Clomipramine—a
nonselective tricyclic—was the first medication studied
in treating OCD in children and adolescents. It is now
usually considered only after two or three failed SSRI
trials because of its potential for cardiac
toxicity.15-17

Dosing. Fixed-dose studies suggest
that dosing schedules for OCD are similar to those used
for depression. For example, sertraline, 50 mg/d, or
fluoxetine, 20 mg/d, are as effective as higher
dosages.18

increasing the dosage too early in the
time-response window for a drug effect to emerge

giving medication without concomitant exposure
therapy.19

Delayed response.
Although many patients respond early to an SSRI, others
do not respond until 8 or even 12 weeks of treatment at
therapeutic dosages. It often takes 3 to 4 weeks for
evidence of benefit to emerge, so wait at least 3 weeks
between dosage increases. Maintain therapeutic dosages
at least 6 to 8 weeks before changing agents or
beginning augmentation therapy.

Two-barrel approach.In treating Adam, we began with sertraline, using a
flexible titration schedule keyed to whether he
experienced OCD symptom remission.

The starting
dosage of 50 mg was titrated to 150 mg over 8 weeks
while he was receiving behavioral therapy. We made
adjustments with a time-response window of 2 to 3 weeks,
allowing us to observe a response to each dosage
escalation.

Adam’s OCD symptoms responded well to
CBT plus sertraline. The maximum drug effect helped him
confront the most difficult EX/RP tasks at the top of
his stimulus hierarchy, which he attacked near the end
of treatment.

Lessons learned.
Multicenter trials have taught important lessons about
drug therapy for OCD:

Drug switching or
augmentation trials often produce only partial response
and cause unnecessary suffering. A more effective
strategy for many patients is to augment drug treatment
with CBT until symptoms normalize.

On the other
hand, augmentation is appropriate when nonresponse or
partial response to SSRI monotherapy leaves a patient
clinically symptomatic and functionally impaired.
Clonazepam, clomipramine, and the amino acid
L-tryptophan have been used successfully. Lithium and
buspirone also have been tried but seem not to be
effective in controlled studies in adults and anecdotal
experience in youth.

When augmenting an
SSRI, adding clomipramine, 25 to 50 mg/d, is a
reasonable choice. However, fluoxetine or paroxetine can
inhibit clomipramine metabolism by cytochrome P-450
(CYP) 2D6, with potential for cardiac arrhythmias or
seizures. Sertraline or fluvoxamine are less likely to
elevate clomipramine levels.20 Fluvoxamine
may be the most compatible SSRI with clomipramine
because it inhibits CYP 1A2—the enzyme that demethylates
clomipramine to its inactive desmethyl
metabolite—thereby preserving more of the active parent
compound.

Clinical evidence suggests that
augmentation’s success may depend in part on a patient’s
comorbidities. For example, clonazepam may be
particularly helpful for children with comorbid panic
symptoms.

Maintenance therapyWe
typically provide 14 weekly CBT sessions, followed by
monthly contacts for a few months to ensure than a
patient’s gains are maintained. Standard procedure with
drug therapy is to continue maintenance treatment for up
to 1 year, although some have suggested continuing
maintenance treatment indefinitely.

King R, Leonard H, March J.
Practice parameters for the assessment and treatment
of children and adolescents with obsessive-compulsive
disorder. J Am Acad Child Adolesc Psychiatry
1998;37(10, suppl):27-45.

March JS. Cognitive-behavioral
psychotherapy for children and adolescents with OCD: a
review and recommendations for treatment. J Am Acad
Child Adolesc Psychiatry 1995;34(1):7-18.

March JS, Mulle K, Herbel B.
Behavioral psychotherapy for children and adolescents
with obsessive-compulsive disorder: an open trial of a
new protocol-driven treatment package. J Am Acad
Child Adolesc Psychiatry 1994;33(3):333-41.

DisclosureDr. March
receives research support from Pfizer Inc., Eli Lilly
and Co., and Wyeth Pharmaceuticals and is a speaker
for and/or consultant to Solvay Pharmaceuticals, Pfizer
Inc., GlaxoSmithKline, Wyeth Pharmaceuticals, Novartis
Pharmaceuticals Corp., and Shire Pharmaceuticals
Group.

Dr. Franklin and Dr. Foa report no financial
relationship with any company whose products are
mentioned in this article or with manufacturers of
competing products.

ACKNOWLEDGMENT Preparation of this manuscript was
supported in part by National Institute of Mental Health
grants 1 K24 MHO1557 and 1 R10 MH55121 to Dr. March and
by contributions from the Robert and Sarah Gorrell
family and the Lupin Family Foundation.